WHO on HIV Therapy: Treat Everyone

New guideline called "dramatic shift"

Everyone with HIV should be offered treatment immediately upon diagnosis, according to new World Health Organization (WHO) guidelines.

The recommendation -- dropping any eligibility restrictions for antiretroviral therapy -- brings WHO advice into line with guidelines in the U.S., and most other Western countries.

The new guidelines also say that all people at "substantial risk" of HIV should be offered pre-exposure prophylaxis (PrEP) with an antiretroviral medication, combined with other prevention methods.

The advice forms part of a revised package of guidelines on HIV treatment intended to be issued later this year, but these two were released early because of their potential to affect public health, the WHO said in a statement.

Expanding therapy to all people living with HIV and increasing prevention options could help avert 21 million AIDS-related deaths and 28 million new infections by 2030, the agency said, citing estimates from the Joint UN Programme on HIV/AIDS (UNAIDS).

The immediate effect is to increase the number of people eligible for HIV treatment around the world, to 37 million people from 28 million under the previous guidelines.

But even today, only about half of those eligible are actually on therapy -- a gap that will have to be closed in order to reap any public health benefits, according to Mitchell Warren, executive director of AVAC, a New York-based nonprofit group that advocates for improved HIV prevention.

"WHO is paving the way for a fundamental shift in the world's response to HIV -- abandoning the partial or piecemeal use of antiretroviral medicines in favor of full access for men and women in need," Warren said in a statement.

"But there is much work ahead to translate them into practice, from securing resources to revamping HIV guidelines in country after country to implementing comprehensive treatment and prevention programs," Warren added.

Expanding access to HIV therapy is at the heart of the so-called 90-90-90 targets for 2020 -- 90% of people with HIV aware of their infection, 90% of those getting treatment, and 90% of people on treatment having no detectable virus in their blood, the WHO said.

The WHO's previous guideline had recommended antiretroviral therapy for those with compromised immune systems, defined as fewer than 500 CD4-positive T-cells per microliter of blood, as well as for vulnerable populations, such as children, pregnant women, and people with TB.

The WHO's decision to change that is a "dramatic shift," the CDC said and is based on science showing early treatment offers benefits both to the patient and to society as a whole.

"As physicians and researchers witnessing the impact of HIV globally, and working to stem its toll, we applaud WHO for taking an important step toward control of the HIV pandemic," Mayer said in a statement.

Aside from the treatment issues, Mayer said, it's important to recognize that access to PrEP can "protect those at substantial risk of becoming infected."

Last year, the CDC issued a clinical guidance recommending physicians consider advising the use of PrEP for gay and bisexual men, heterosexuals, and injection drug users at substantial risk for HIV infection.

The 2014 WHO guidance on the issue recommended PrEP for men who have sex with men, but said it could be offered to heterosexual couples where one partner had HIV and the other did not and to men and transgender women who have sex with men.

But "further evidence of the effectiveness and acceptability of PrEP," the WHO said, now supports a broader recommendation that would include all people at high risk of transmission.

The agency added that PrEP should be "an additional prevention choice based on a comprehensive package of services, including HIV testing, counseling and support, and access to condoms and safe injection equipment."

Development of the guidelines was supported by the United States Agency for International Development, the CDC, and the Bill & Melinda Gates Foundation. Many study authors reported potential conflicts, both financial and non-financial, that were deemed significant; such authors were excluded from the decision-making process where their conflicts impinged on the discussion.

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